Pain as the fifth vital sign is a movement that began in the 1990s, seemingly in response to inadequate attention to patients’ pain. While it is generally recognized that the abundance of narcotic prescriptions written by physicians is at the root of a growing epidemic, some public health experts attribute the rise in these prescriptions to this initiative launched by the Veterans Health Administration. Although opioids have traditionally been the workhorse of pain relief for both acute and chronic pain, the current pattern of use and abuse has spurred a new focus on multimodality treatment, including preoperative and postoperative regimens, for the safe and adequate treatment of pain.

A surgeon’s perception of a patient’s pain is subject to inherent biases, which have been shaped and molded by experience. Unlike the patient, physicians cannot rely on internal cues and must make external assessments and judgments based on whether the patient is being truthful, what is an acceptable or expected amount of postoperative pain, reasonable treatment measures, and what may be drug-seeking behavior. There are several ways to approach pain treatment to shift the mind-set regarding postoperative pain management; however, the largest body of evidence-based protocols is issued through the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR), which the American College of Surgeons (ACS) recently launched in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. Formerly known as the AHRQ Enhanced Recovery After Surgery (ERAS) program, ISCR provides multidisciplinary strategies for effective perioperative pain management and requires therapeutic agreement among surgeons, anesthesiologists, as well as patients and their families.

Implicit bias and the perception of pain

A major hurdle facing physicians who seek to alter their prescribing patterns is a lack of awareness regarding the effect of their implicit biases on assessment and treatment of patient pain. Although many facets of patient care are likely to be influenced by the subtle attitudes, assumptions, and stereotypes that constitute an individual’s unconscious judgment, the evaluation of pain is uniquely susceptible to these biases given the subjective nature of an individual’s response to painful stimuli. Factors known to influence a provider’s assessment of patient pain include patient-reported symptom severity, judgments regarding patients’ trustworthiness, the provider’s preconceived notion of how painful a particular procedure “should be,” prior clinical experience in managing various disease states, and the degree of empathy that a prescriber feels toward any given patient or patient population.1 Most often, internal conflict arises when patient reports of pain symptoms are incongruent with objective clinical signs.

Although visual aids, such as the Wong-Baker FACES Pain Rating Scale, may diminish the subjective nature of a patient’s pain complaints, physicians are trained to approach these assessments with some skepticism.2 Although a clinician would be justified to question the reliability of a comfortably resting patient who cries out in “10/10” pain upon stimulation, studies have demonstrated a correlation between patient appearance and how trustworthy they seem to their physician. Furthermore, pain judgment biases have been shown to be rooted in clinicians’ perceptions of patient ethnicity, age, gender, skin color, socioeconomic status, and attractiveness.3 Unsurprisingly, many of these same factors influence the prescribing patterns of analgesic agents.4,5

One factor shown to mediate implicit attitudes about pain assessment is clinician experience. Previous experience is of particular relevance when considering the capacity of surgeons to appropriately manage postoperative pain. Whereas inexperienced trainees may underestimate the pain associated with fascial sutures or “minor” anorectal procedures, they may be equally as likely to overmedicate a “squeaky wheel” patient on a busy call night. On the other hand, experienced providers may consciously or unconsciously undertreat patients who remind them of prior drug-seeking individuals or they may fall into the trap of overtreating pain complaints to achieve improved patient satisfaction scores. One common thread in many of these potential scenarios is the physician’s failure to appreciate implicit biases. Use of procedure-specific ERAS protocols is among the recently proposed methods to combat implicit biases.6

Opioid treatment of chronic pain

Opioids are the traditional treatment for acute surgical pain, but they are poor treatment choices for chronic pain. Approximately 11.2 percent of adults in the U.S. experience chronic pain, 3 to 4 percent of whom are maintained on chronic opioid therapy.7-10 Health care professionals who treat these patients must be cognizant of the associated elevated risk, as surgical patients on chronic opioid therapy may have significantly increased hospital lengths of stay, readmission rates, health care expenditures, and mortality rates than patients who are not on chronic opioid therapy.7

Acute pain and chronic pain are distinct from one another, with chronic pain management posing a particular challenge to patients and health care providers alike.8 Acute pain is part of a normal physiologic process in which an uncomfortable external sensation, such as tissue damage, leads to noxious neurologic stimuli. By definition, acute pain lasts less than one month, though it may be followed by dull pain as a result of persistent inflammatory mediators within the tissue. As this tissue damage is repaired, a temporary period of hypersensitivity often is followed by resolution of the pain. In cases of chronic pain lasting more than three months after injury, severity and duration do not coincide with the presence of a noxious stimulus nor with the severity of injury.8 Risk factors associated with the development of chronic pain include around-the-clock dosing of narcotics, overall duration of narcotic therapy, and the specific type of narcotic prescribed.11

Most surgeons are amenable to operating on patients with a chronic pain syndrome, despite knowing full well that a surgical intervention will likely potentiate both their acute and chronic pain. Furthermore, control of procedural pain may be difficult in those patients who have developed tolerance secondary to chronic opioid use. The surgeon should feel comfortable involving other health care providers, such as pain specialists and pharmacists, in the treatment of patients who present with preexisting chronic pain or who develop chronic pain after treatment of a surgical disease. Chronic pain is not a treatment failure. It is a distinct clinical condition that requires considerable expertise, effort, and time to achieve adequate treatment. Familiarity with the normal course of acute postoperative pain following surgery aids in identifying the early stages of chronic pain and opioid dependence, and allows for early referral to a chronic pain specialist.

Implementation of ERAS protocols across many specialties has been shown to reduce rates of opioid use.12,13 Pioneered in colorectal surgery, these protocols address pre-, intra-, and postoperative variables, such as fluid balance and nutrition to ensure a more effective recovery from an operation. Multimodal pain management is a critical component of these protocols, with heavy reliance on non-narcotic pain medications aiding in quicker recovery and reduction of postoperative narcotic use.

Effective development and execution of the ERAS analgesic regimens requires multidisciplinary communication and care coordination. Surgeons must collaborate with perioperative and floor nurses as well as anesthesia providers to deliver analgesics beginning in the preoperative patient holding area. Acetaminophen, cyclooxygenase (also known as COX) inhibitors, and gamma-amino butyric acid (also known as GABA) analogs administered preoperatively help to blunt initial nociception and consequently may decrease postoperative pain. These agents also constitute the backbone of the multimodal postoperative analgesic regimen to be used in addition to narcotic agents. Regional anesthesia modalities, including nerve blocks and epidurals, also can decrease the need for global anesthesia and/or systemic narcotics postoperatively. Adjunct anesthesia agents like intravenous ketamine and lidocaine can be continued postoperatively to decrease immediate postoperative pain. Multiple studies have shown that patients complain of less postoperative pain after undergoing multimodal regimens.13-15 Diminished opioid use is therefore secondary to both decreased pain levels and the availability of alternative analgesics.

Opioid management training

The patient pain management challenges that health care professionals face are, in part, the result of their limited education in the treatment of pain.11 This deficit becomes most noticeable when practice patterns are examined following the introduction of pain management education. In one study, introduction of procedure-specific recommendations enabled surgeons to reduce the number of narcotic pills that they prescribe by more than 50 percent; patients who received opioids were adequately managed by the initial prescriptions in 80 percent of the 246 cases studied.6 Unfortunately, formal curricula for pain assessment and management in postoperative patients is lacking in both breadth and standardization. Though some courses have demonstrated improvements in analgesic prescribing patterns after implementation of a mandatory palliative care curriculum for residents, no nationally recognized or mandated pain management courses are available to surgical residency programs.16-17 Furthermore, residents receive minimal training and education in multimodality analgesic administration.

Most residents learn pain management strategies from those surgeons who have gone before them. This trend extends to both analgesic selection and appropriate dosing for each level of pain severity and tends to favor opioid use. Beyond this exposure, junior-level resident pain management strategies typically are subject to trial and error, often with arbitrary increases or decreases in dosages based on the subjectively reported level of pain, with the addition of nonopioid analgesics chosen in a “dealer’s choice” fashion. Patients with preoperative chronic pain or with symptoms that fail to be controlled with conventional methods are often referred to pain management specialists while they are in postoperative recovery.

To mitigate the growing crisis, surgeons need to develop a deeper understanding of the relationship between symptoms, prescribing patterns, educational interventions, and subsequent outcomes. The University of Toronto, ON, has instituted a multidisciplinary transitional pain service to manage patients with chronic postoperative pain and reduce opioid use.18 The university’s pain research unit found that 70 out of 200 consecutive patients continued to have pain at three months, and researchers noted continued use of oral opioid agents in 27 percent of postoperative patients with persistent pain. Although these patients reported pain levels that were lower than those patients taking nonopioid agents for persistent pain, opioid users reported lower overall health, mood, and ability to return to work. Although the findings presented by the University of Toronto’s pain research unit highlight important issues surrounding over-prescribing of narcotics to postoperative patients, insufficient attention is paid to the risk of developing dependence or chronic postoperative pain, let alone strategies for management of these conditions. These studies and others like them provide promising information, but strategies for effective opioid management training require further study.

A general approach to improved treatment of surgical pain

Surgeons striving to improve patients’ postoperative pain while minimizing opioid use should consider the following strategies:

Early referral to a pain management specialist for patients with prolonged or atypical pain, and preoperative collaboration with a pain management specialist for patients who are already receiving chronic opioid therapy

Use of opioid-sparing regimens in the perioperative period (for example, ERAS protocol via ISCR collaboration)

Review of the expected postoperative pain course at the postoperative visit with an emphasis on the appropriate time at which the patient should no longer be requiring opioids

Pain is a necessary but undesirable consequence of surgery. Consequently, surgeons are responsible for understanding effective treatment of acute pain as well as the care of surgical patients with an acute exacerbation of chronic pain. Internal implicit biases about level and degree of postoperative pain from both surgeons and patients must be reconciled. The presence of chronic opioid use must be accounted for when tailoring postoperative analgesia, with an emphasis on early collaboration with pain management specialists. We must use our best judgment to provide appropriate therapy and should implement strategies such as ERAS protocols to reduce prescribing of narcotic medications. Expansion and standardization of resident education may aid in a physician-led attempt to address the growing opioid epidemic in the U.S.